Thoracic Back Pain in an Intercollegiate Female Rower Mike Lawler M.A., ATC, LAT Senior Associate Athletic Trainer The University of Iowa

Introduction Case presentation Discussion Conclusions

Rowing at Iowa Beginning 16th year as an intercollegiate sport 60-70 rowers on team Varsity and Novice Practice for 2½ hours on water and 1 hour with strength & conditioning coach

Case Presentation 20 YO female rower for the University of Iowa. No previous experience as a rower prior to enrolling at Iowa in 2005. Onset: April 12, 2007 during spring season - 3 weeks left in her season CC: Swelling and pain at left anterior rib cage Painful left upper back; Pain while rowing in practice Numbness at left mid back below scapula Occasional dyspnea Previous hx: None; gradual onset with no acute episode Continued to participate in practices until symptoms worsened and performance became affected Symptoms initially only with rowing but now during ADL’s

Examined by certified athletic trainer in athletic training room Assessment: Possible costochondritis; posterior rib stress reaction; paraspinal strain treated with therapeutic modalities Cold/ice bag allowed to continue rowing, as tollerated After one week her symptoms failed to improve She was referred to UISMC and orthopaedic physician on April 18, 2007

Musculoskeletal Injuries 1994 - 2006 Low Back 104 27.7% Knee 49 13.1% Chest/Rib 40 10.7% Upper Back 26 6.9% Ankle 25 6.7% Wrist 23 6.1% Shoulder 17 4.5% Patella 17 4.5% Hip 16 4.3% Foot 16 4.3% Tibia 13 3.5% Neck 8 2.1% Elbow 7 1.9% Forearm 6 1.6% Fibula/Calf 3 0.8% Finger 2 0.5% Other 3 0.8% TOTAL 375 100%

Physical Examination by Orthopaedic Team Physician – 4/18/07 Examination findings: Slight prominence of the costochondral joint from anterior left side of chest Palpable tenderness in left paraspinal muscles Numbness noted in the left thoracic paraspinal area Posterior thoracic pain is aggravated with motion in all directions Upper extremity function was normal Neurologic exam: normal Radiograph studies:

L-Spine Standing AP & Standing Lateral Flexion/Extension views X-rays L-Spine Standing AP & Standing Lateral Flexion/Extension views Findings/Impression: There is no evidence of a fracture or dislocation. The osseous structures are in gross anatomic alignment. There is no soft tissue abnormality Negative exam

Impression Costochondritis left anterior rib cage Referred pain posteriorly Thoracic radiculopathy

Plan Provided prescription for naproxen – 500 mg BID MRI imaging was offered to rule out thoracic disk herniation if sx.’s fail to improve or worsen Progress to be followed by staff athletic trainer She was able to finish out spring season but not without resolution of symptoms; treated symptomatically.

Status as of August 22, 2007 prior to start of 2007-2008 season 2-3 months of no rowing during summer Unproductive chiropractic treatments during summer Resolution of left anterior chest swelling Same amount of continuous pain, described as a “pinching” just below scapula on left side When active, pain increased but was less severe than when she would row Patch of numbness was still present just below left scapula Numbness had slightly migrated to right side of back and up right side of her back to just above right scapula She had not noticed any UE weakness

Return Visit to Orthopaedic Team Physician – 8/22/07 Examination findings: Palpable tenderness about T10 just to left of thoracic spine. No other tenderness Numbness noted inferior to left scapula No palpable tenderness of anterior chest wall Increase of pain with lateral bending and twisting. No pain with flexion & extension Chest X-rays - normal

Plan MRI imaging was scheduled to rule out thoracic disc herniation Reasoning? Persistent pain Patch of numbness Pain with movement To look deeper for a cause

Thoracic & Cervical MRI Findings A small syrinx within the midthoracic spinal cord from the T6 through portion of T8 levels, measuring 1.8 mm max. diameter Above and below syrinx, thin central high T2 signal appeared most consistent with normal spinal CSF central canal No abnormal focus on enhancement No underlying lesion was identified Spinal cord signal was otherwise unremarkable No central stenosis Cervical & thoracic spine exhibited no degenerative changes Normal configuration of the intra cranial posterior fossa structures, without evidence for Chiari malformation

Syrinx A syrinx is a fluid-filled cavity within the spinal cord (syringomyelia) or brain stem (syringobulbia). Taber’s Cyclopedic Medical Dictionary Symptoms include flaccid weakness of the hands and arms and deficits in pain and temperature sensation in a capelike distribution over the back and neck Sx.’s not reported by this patient

Syrinxes usually result from lesions that partially obstruct CSF flow. At least ½ of syrinxes occur in patients with congenital abnormalities of the craniocervical junction (eg, herniation of cerebellar tissue into the spinal canal, called Chiari malformation), brain (eg, encephalocele), or spinal cord. For unknown reasons, these congenital abnormalities often expand during the teen or young adult years. A syrinx can also develop in patients who have a spinal cord tumor, scarring due to previous spinal trauma, or no known predisposing factors. About 30% of people with a spinal cord tumor eventually develop a syrinx. Source: Merck Manual online

Referral to Spine Team Physician - 8/27/07 Exam Findings LE neurovascular exam – normal Tenderness to palpation over posterior rib at T8 level on left Chest x-ray showed a possible lytic lesion on left 8th rib posteriorly No indication of myelopathic findings – syrinx is not likely cause of her symptoms Plan: Obtain CT scan of 7th – 9th posterior ribs

CT Scan of Ribs Axial CT scanning of the mid and lower thoracic spine and medial aspect of of the ribs was performed without intravenous contrast FINDINGS: No lytic or sclerotic lesions were identified in the medial aspects of posterior ribs. No abnormal soft tissue masses were identified. There were no degenerative changes of the visualized thoracic spine IMPRESSION: No abnormality in the medial aspects of the mid and lower thoracic ribs.

Where do we stand at this point? Ongoing symptoms of back pain in middle aspect of spine, left side “Numbness” in her back on left side Mid thoracic spine and left paraspinal tenderness MRI showed syrinx that was determined to not be cause of symptoms CT scan showed no abnormal findings Chest x-ray read as normal Treatment with therapeutic modalities: heat, e-stim, ice Prior pain in left anterior aspect of ribs has resolved Still experiencing pain while rowing – participation is limited

Plan Continue local therapeutic modalities Neurosurgery consult for possible facet or nerve root injection Medrol dose pack for competitions Follow-up with team orthopaedic physician and/or Spine Team orthopaedic physician prn Allowed to participate, as tollerated

Referral to UIHC Pain Clinic – Neurosurgery Consult Received costovertebral/costotransverse injection on 11/02/07 Allowed to return to rowing activity Patient reported that “the injection helped for a little while but then wore off.”

Additional Referral and Treatment Medication changed from Naproxen to Piroxicam Second series of 2 injections at T9 and T11 on 11/28/07 Prescribed Lidoderm patches by Pain Clinic physician Treatment with iontophoresis in athletic training room Treatment with T.E.N.S.

Spring 2008 Rowing Season 2008 Winter Training Trip Stationary bicycle – no erging, only drill work on water February – May 2008 Continued to row until pain forced her to rest Repeated this pattern throughout spring 2008 Reported previous injections had somewhat helped because pain was not as intense Persistent symptoms of skin sensitivity and “numbness” Attended follow-up care with UIHC Pain Clinic Allowed to finish out season, as tolerated

Fall 2008 Rowing Season Resumed practicing with recurrent symptoms of pain, tenderness over posterior ribs, just to left of thoracic spine, and mid-back and left side numbness Symptoms presented during rowing and strength training activities, diminished with rest Continued to participate in most practices and competed in all fall races End of fall season follow-up with Spine team orthopaedic physician

Follow-up Examination with Spine Team Orthopaedic Physician – 12/15/08 Review of 8/22/07 MRI findings Benign other than incidental thoracic syrinx not felt to be contributing to her symptoms Neurovascular exam was normal Plan: Repeat thoracic spine MRI with contrast to evaluate any progression of syrinx Renew prescription for Lidocaine patches

Repeat Thoracic Spine MRI with Contrast IMPRESSION: Stable mid thoracic small syrinx No lesion visualized PLAN: Refer back to team orthopaedic physician and Pain Clinic for continuation of care

Spring 2009 Rowing Season Participated, as tollerated, in Winter Training Trip Continued to experience pain and numbness sx.’s Treatment with: Lidoderm patches T.E.N.S. Iontophosesis NSAID - Piroxicam Participated in spring practices and races “good days and bad days” Finished out rowing career on May 17, 2009 Graduated from the University of Iowa

Discussion Hx. of chest/rib pain in rowers Discovery of benign syrinx by MRI Multidisciplinary team approach to care of patient Multiple treatments used with varied results Even with best efforts, there was a failure to achieve complete relief of symptoms Conclusive diagnosis?

Conclusions MRI showed a midthoracic small spinal cord syrinx that was concluded to not be cause of her symptoms Persistent mid-thoracic back pain and numbness “It’s not about what it is, but what it isn’t” No rib stress fracture No herniated thoracic disc No abnormal soft tissue masses No degenerative changes of thoracic spine

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